Managing Pain in End-of-Life Care

I spent only one night in the intensive care unit.  Then they brought me back to my own room, where I experienced the discomforts one normally encounters after going through extensive surgery.  I wanted to pray, but the physical discomfort was overwhelming.  I remember saying to the friends who visited me, �Pray while you�re well, because if you wait until you�re sick you might not be able to do it.�  They looked at me, astonished.  I said, �I�m in so much discomfort that I can�t focus on prayer.  My faith is still present.  There is nothing wrong with my faith, but in terms of prayer, I�m just too preoccupied with the pain…
Joseph Cardinal Bernardin, The Gift of Peace

Pain is much more than an unpleasant sensation experienced by a patient.  It can affect the total life of the patient.  Pain can impair physical functioning, affect a patient�s mood, and hinder social interaction.  As Cardinal Bernardin pointed out, pain can even affect the patient�s ability to pray.

The Ethical and Religious Directives for Catholic Health Care Services from the National Conference of Catholic Bishops (1994) affirms that �patients should be kept as free of pain as possible so that they may die comfortably and with dignity…� (no. 61).

Many people are reluctant to use narcotic medication to relieve severe pain because  of a fear of becoming addicted.  Actually, this fear is unwarranted.  First, addiction rarely occurs in a healthcare setting.  One estimate is that �less than 0.1% of patients develop addiction� (Lisson, �Ethical Issues in Pain Management,� Seminars in Oconology Nursing, May 1989).  Further, a distinction can be made between addiction and drug dependence.  In the case of drug dependency, the drug has a medical value for the person taking it, and the dependence is a physical one. Withdrawal symptoms will occur if the drug is taken away suddenly, so that it needs to be taken away gradually over a period of time. Addiction, on the other hand, is a psychological problem.  The drug has no medical value for the person taking it, but the individual desires it and is driven to obtain it.  A dying patient may become physically dependent on a drug, but this does not mean that she or he is addicted to it. And, in the case of dying patients, the pain medication need never be withdrawn to cause any distress.  Knowing the difference between �drug dependence� and �addiction� can be reassuring to patients and their families.

An ethical question about pain management has concerned the use of pain medication in circumstances which may hasten the patient�s death by depressing respiration.  Some fear that they are engaging in an act of euthanasia when administering pain medication in such circumstances.  However, the Catholic Church has taken the position that �medicines  capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person�s life so long as the intent is not to hasten death� (Ethical and Religious Directives for Catholic Health Care Services, no. 61).  But how does one judge intent?  This is one way: if a patient�s pain is relieved by a certain dosage level of the pain medication, the level will not be deliberately increased to risk depression of respiration (and death).  This indicates that the intent is indeed to relieve pain.

Fortunately, we are beginning to move beyond this problem with pain medication.  For one thing, more is now known about how to administer pain medication in a way that  avoids depression of respiration: �…some patients may need, and can tolerate, 1,000 milligrams or more of morphine per hour, as in intravenous infusion, to control the ferocious pain of some cancers.  Such doses are not reached overnight but infusions  are judiciously titrated upwards in measured increments until pain is contained.  In this way respiratory distress does not occur, since unrelieved pain acts as a physiological antagonist to the respiratory depresssent effect of the opiate drug.� (Catholic Health Association, Care of the Dying, 1993)

Although most pain can be successfully managed, some dying persons do experience severe pain which cannot be relieved by methods currently available.  In these cases some people push for euthanasia or assisted suicide as a way of relieving the suffering of  those who are dying.  An alternative is sedation of the patient to the point of unconsciousness on a continuing basis until death occurs.

The moral permissibility of sedation which suppresses consciousness has been addressed by Pope John Paul II in Evangelium Vitae (The Gospel of Life): �Pius XII affirmed that it is licit to relieve pain by narcotics, even when the result is decreased consciousness and a shortening of life, �if no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties.� …All the same, �it is not right to deprive the dying person of consciousness without a serious reason�: as they approach death  people ought to be able to satisfy their  moral and  family  duties,  and above all they ought to be able to prepare in a fully conscious way for their definitive meeting with God.� (65) Similarly, the Ethical and Religious Directives for Catholic Health Care Services states: �Since a person has the right to prepare for his or her death while fully conscious, he or she should not
be deprived of consciousness without a compelling reason� (no. 61).

In sum, the practice of sedating patients to the point of unconsciousness on a continuing basis until death occurs does not seem to be totally excluded by Catholic teaching, but must be approached cautiously and with restrictions attached.  There must be a �serious� or �compelling� reason for depriving the patient of consciousness. (Undoubtedly, some would  contend that unrelievable pain which is so severe that it makes a patient repeatedly request euthanasia or assisted suicide satisfies this condition.)  Further, we must ensure that the patient has had the opportunity to satisfy practical and moral obligations which require maintaining consciousness (e.g.,  settling important inheritance matters, becoming reconciled with estranged family members) and to prepare spiritually for death (e.g.,  receiving Viaticum). In addition, ethicists would want to add the condition that such sedation should be undertaken only with the consent of the patient, if he or she is mentally competent.

Prepared by Janine Marie Idziak, Ph.D.  Health Care Consultant, Archdiocese of Dubuque, IA  July 2000    This document may be reproduced.